you don't have to be mad to work here...
It’s official, mental health services in the UK have hit the tipping point and are heading for meltdown.
Mental health services have always been the daggy mate of health care, easy to abuse and leave waiting by the phone. And with our professional bodies, NHS England and Monitor, proposing that mental health have an additional 20% cut in funding beyond the already abusive cuts it’s fair to say that the NHS is just not that into us.
The mental health crisis isn’t just about service users, it’s also about the people that provide those services. In the main, and I don’t wish to get too technical for you here, the therapists delivering mental health services are chumps and I say that as someone who worked in the NHS low down on the mental health food chain. The reason is that we are working under an employment relations system which is essentially Dickensian but without the laughs. From clinical psychologists to community health workers, you don’t have to be mad to work in mental health but it’s extremely likely.
The idea of a psychotherapist brings up warm calm images of grey haired folk in mauve and beige in consulting rooms peppered with ethnic objects and Afghan rugs. This is absolutely not the reality for most clinically trained people.
The UK’s largest adult therapeutic programme, Increased Access to Psychological Therapies (IAPT) is an ambitious one aimed at getting people back to work. It uses high and low intensity Cognitive Behavioural Therapies (CBT) interventions for between four to sixteen weeks, mainly at primary care level or dedicated psychotherapy providers. This is a particularly standardised form of CBT not designed to deal with serious mental illness and as a result much of the therapy is done over the phone or is “self-guided”.
The justification for this huge increase in talking therapies is firmly economic. The costs of our collective decline to the UK’s economy has become too high and there are hopes that by increasing mental health services we will see a rise in what we laughably call employability, productivity and a way out of this recession.
The people that deliver IAPT services are no longer called therapists, they are Psychological Wellbeing Practitioners (PWPs), many of whom are in fact experienced therapists and clinical psychologists, punching below their weight and wondering whether it was worth the many years of clinical training and internships to be professionally downgraded. This is the clinical equivalent to online dating where you are given 30 minutes to get to grips with complex and often hopeless situations, lie about what you can do and walk away from human tragedy without a care in the world.
The changing nature of the employment relationship affects therapists in three main ways.
The first relates to internships, or the widespread use of honorary psychotherapists. Adult psychotherapy training involves a minimum of 4-6 years of part time training. During that period the most important part, along with your own personal therapy, is to carry out clinical work. In the case of adult therapy, this work is carried out under supervision with the support of high quality training and practitioners. The problem is that we don’t get paid, hence the reference to chumps. In order to train as an adult psychotherapist in this country you have to work part time (usually 1-3 days a week) for free for between 4-6 years. The fact that we learn a trade means that this is not literal bonded labour, more like an apprenticeship for quite old people.
Our professional bodies are complicit in this system of unwaged work, receiving much needed funding from the state for supplying trainees for free. It means that the professional bodies charged with building a sustainable profession are fundamentally unable and unwilling to do that. To demand wages for the people that provide a large chunk of NHS services is not in their financial interest and as a result this is a profession open to primarily independently wealthy people. There are some who work full time and do the training on top, but with work intensification and the sudden death of training and development in 2008 if we are not careful the vast majority of practicing therapists will be rich people. That is not to say that rich people make worse therapists than poor people, but it does raise important questions about class and power both clinically and within the profession.
Marx had something to say about honorary psychotherapists. Well, not exactly but he had a lot to say about the role of the unwaged and unemployed putting a downward pressure on employment. As long as we are offering our work for free, and doing it quietly and diligently, the NHS as an employer will never get its act together and adequately pay the people that work for it.
The second employment relations issue is that of externalisation or triangulation where a third party is involved in the employment relationship. The advent of Private Employment Agencies (PrEAs) is nothing new in healthcare but with the massive rise in demand for IAPT services, cuts and waiting lists for between 6-18 months we are now seeing the creation and expansion of private employment agencies for therapists. Because of the intense insecurity of this work nobody wants to talk about it so there is no comprehensive data about how many therapists now work for PrEAs but anecdotally it’s on the increase as private companies steadily buy up IAPT waiting lists.
As with all externalised employment relations, it’s not just the contract of employment that gets passed over to third parties, it’s also the responsibilities of employers. There is a large body of literature dedicated to how employers avoid their responsibilities through subcontracting and the subsequent difficulties in regulation. Many people working for agencies do not have a written contract of employment, receive no training or supervision. This is particularly true for therapists who can find themselves working in conditions no better than a call centre, providing therapy without any idea who their employer is and no clear duty of care. These difficult choices are then passed onto the patient, where therapists in these subcontracted choose between caring for the patient in a way that may be hateful and humiliating or not treating them at all.
An example. PWPs' work is formalised and standardised to the extent that if a patient does not pick up the phone for an initial assessment, within a 15 minute allotted time period they are referred back to their GP, presumably to wait for a further 6 months.Within these services there is a hatred for the patient that keeps us on the phone for too long, making it impossible to meet the quota of 8 satisfied clients a day. Reaching the quota involves not listening to the real and deteriorating situation of patients. Under these conditions the only way to responsibly help patients is to refer them on to other more intensive services. Hatred is passed on, dump and run.
PWPs that offer more support, mainly through giving more time and going off script, are forced to keep this secret from employers because it breaks their contract of employment, leaving them to carry the full ethical and clinical consequences of their interventions. I doubt you could get clinical insurance to cover this situation and it exposes therapists to precarious states of mind, counterproductive for people employed to contain the anxieties of others.
The third impact relates to those therapists left within the NHS system. Often scared, overworked and definitely feeling guilty for raising their concerns with colleagues who will never see sick leave or pensions again. The Francis reports clearly state that the NHS manages us through systemic bullying. Do this or lose your job, where targets can only be managed through systems of command and control. It is a stomach churning reality that the NHS rests on bullying the people that are supposed to protect vulnerable service users. Often the people with the best contracts end up with the worst jobs, internalizing the guilt of a system which treats its workers as if they were ancillary to their survival.
So the workforce is made up of these three precarious groups: interns, temps and scared public sector workers. There is no question we will see more failures in care, whistleblowing and burn out if this employment relations problem isn’t addressed. Many experienced and wonderful therapists have retreated to private practice, unable and unwilling to navigate a broken system. This means that there is some great therapy available out there, but only for those people that can afford it. It’s not to say that private practice doesn’t offer massively needed services, it does, and a careful assessment and referral can make the difference between life and death. But it also means that anyone without money is left behind, looking at therapy as a kind of psychic pilates, available only to those that can pay or live in North London.
In a context of deteriorating mental health in the UK the fact that we are a disorganised and chaotic group of people is a matter of both professional and personal ethics. We don’t need any more mental health policies that do not address the mental health of the people that are expected to deliver these services. The current economic argument for cheap therapy is based on the profound and unacceptable working conditions of the thousands of dedicated therapists in the UK and we have now hit breaking point.
A few years ago me and a friend working on a PICU ward in the NHS struck by the mental distress of the staff rather than the patients tried to set up a trade union for insecure mental health workers. To try to encourage people to join up we did this online and guaranteed anonymity for everyone that joined. Despite contacting hundreds of mental health workers only 2 people signed up. They were too scared to disclose their situation anonymously online. That statement should chill you right to the bone.
It might feel like I’m punching kittens to point out that although we’re feeling vulnerable it is for us to bring about changes at work. If the entire history of industrial democracy is anything to go by it is the collective responsibility of psychotherapists to raise our consciousness sufficiently to argue the point that we should all be paid and protected at work. Mental health workers need to start talking about what’s really going on and being brave enough to raise the issue of jobs and wages at work. It means talking about wages in our supervisions, professional and group meetings, conferences and CPDs and insisting on employment relations having a permanent place on the agenda. It also means that our professional bodies need to start listening to the people they are supposed to be defending and preparing for the day when this motley crew turn up to negotiate pay and conditions. This is not a political battle, it’s a professional one but it inevitably means employers and employees putting their cards on the table.
Talking and listening, not too much to ask.